PolkCountySchool District

Request to Conduct Research Form

Title of Study:

Name of Principal Researcher:

Address:

City:State: Postal code:

Home Phone: Office Phone: Email:

Title/Position of Applicant:

Name(s) of other researchers, if applicable:

Name/Title/Address of sponsor regarding this research project (e.g., Director of Agency, Student’s Advisor, etc.):

Short Topic of Study (6 words or less):

Purpose of Study:

Description of Methodology:

Specific data-gathering instrument(s) to be used (please attach) and description of reliability and validity evidence to be obtained:

Study Time Frames:
Proposed Start Date:
Proposed Completion Date:
Number of Students/Participants
Grade Level/Age / # Of Students Required / Relevant Characteristics

Estimated time required of each student/participant:

Estimated time required of school personnel (e.g., classroom teacher, staff, principal, etc.):

Do you propose use of existing instruction time?

If not during instructional time, when is the study to be carried out?

Is access to school records required?

If so, state the nature of information required:

Describe measures to insure:

Confidentiality of responses:

Anonymity of respondents (mandatory, if respondents are students):

Please state the nature of any possible risk(s) to participants, psychological or otherwise, that might arise:

Please state the nature of any benefit(s) to participants (school/student) that might result during this study:

Date the District will receive results/conclusions of this study:

Please Note: In addition to Research Review Board approval, parental consent and principal permission must be obtained before beginning any research activity.

The following information must accompany the application and be assembled into three identical packets:

  1. The completed “Request for Research” form

2. A brief abstract, not exceed 200 words

3.A detailed research proposal

  1. A sample letter to parents/guardians requesting permission for student participation (where appropriate)
  2. A letter from principals/teachers granting permission to conduct research in their school/classroom (where appropriate)
  3. Evidence of recent (within five years) human subjects research training. College and university affiliated researchers must obtain approval of their proposed research by their Institutional Review Board or similar committee. Evidence of approval must be submitted before any data is collected.

Signature of principal researcher: ______Date:______

Signature of sponsor: ______Date: ______

Title of sponsor:

Questions regarding requests for research may be answered by

Polk County Schools

Office of Assessment, Accountability and Evaluation

1915 South Floral Avenue

Bartow, FL 33830

(863) 534-0736 / Fax (863) 534-0770

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